Intended for healthcare professionals


The NHS through American eyes

BMJ 2000; 321 doi: (Published 23 December 2000) Cite this as: BMJ 2000;321:1545

It has an enviable goal and constancy of purpose: build on it

  1. Sheila Leatherman, senior associate (,
  2. Donald M Berwick, chief executive (
  1. Judge Institute of Management, Cambridge University, Cambridge CB2 1AG
  2. Institute for Healthcare Improvement, 375 Longwood Avenue, Boston, MA 02215, USA

Criticism from without, demoralisation within, and ubiquitous scepticism besiege the National Health Service. The NHS Plan, released in the summer,1 is the latest in a series of blueprints intended to redefine the resources, programmes, and operating principles of the NHS, but it too has met its share of cynics. We are two Americans, privileged to have an inside view of the NHS and its proposed reforms, and we share an optimism about the NHS that is hard to find in the UK nowadays.

Not that we don't see the trouble. The performance problems of the NHS are no secret. Some reflect random episodes of malfeasance, such as the murderous Harold Shipman, but more chronic problems afflict the NHS as a whole and, in aggregate, cause far more suffering and waste. They include long waiting lists, postal code variation in practice, and poor outcomes in cancer care, and they caused the UK to lag ninth out of 15 European Union countries in the World Health Organization's recent ranking of health systems.2 Yet, while many in the UK wring their hands over the problems, we continue to believe that the NHS has fundamentally “got it right.”

Firstly, the …

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